Intake for Cheng Integrative Acupuncture
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Consent to Treatment and Consultation
By signing below, I understand that I am the decision maker for my health care. Part of the acupuncturist’s role is to provide me with information to assist me in making educated choices. I have been informed of the care recommended, the benefits and risks associated, alternatives, and the potential effect on my health if I choose not to receive the care. I consent Acupuncture and Oriental medicine treatments which may include: Acupuncture: this involves insertion of sterile, disposable tiny needles. Possible risks include temporary discomfort, minuscule bleeding on the skin. Rare risks (extremely low incidence when acupuncture is administered properly) include fainting, nerve damage, organ puncture (pneumothorax) and infection. I will report to the acupuncturist any dizziness or lightheadedness during or after a treatment. Heat Treatment with an Infrared lamp: This is used to warm an area of the body. Every precaution is taken to prevent over warming, but the rare possibility of a mild burn exists. Moxibustion/Moxa: Moxibustion is the burning of an herb (mugwort). There is risk of being burned in small areas such as the ash falling on the skin.Cupping, Gua Sha: Cupping is a treatment of creating a vacuum in glass or plastic cup. Discoloration of the skin and bruising are expected. Rarely a slight burn or blister may also appear. Gua Sha is scraping on the skin using a smooth edged instrument. Both can bruise which typically isn’t painful and resolve in 3-7 days.Herbal, supplemental, nutritional recommendation: Optional and educational information on herbs and latest nutritional research.Oriental bodywork/Tui Na: a form of massage based on oriental bodywork principles which can use liniments, oils, but not chiropractic manipulation and/or adjustment. Risks may include soreness, bruising and or increased pain post treatment.While I do not expect the clinical staff to anticipate and explain all possible risks and complications of treatment, I wish to rely on them to exercise judgment based upon the facts then known, and in my best interest. I understand that, as with all healthcare approaches, results are not guaranteed, and there is no promise to cure. Acupuncture is not intended to substitute for diagnosis or treatment by medical doctors or to be used as an alternative to necessary medical care. I understand that I must inform the acupuncturist of any medical history, family history, medications, and/or supplements being taken currently (prescription and over-the-counter). It is expected that you are under the care of a primary care physician or medical specialist if you have hypertension, cardiac conditions, diabetes, acute ab pain, fracture or dislocation, undiagnosed neurological conditions, unexplained severe weight loss,suspected systemic infection, serious hemorrhage disorders. Pregnant patients are seeing an appropriate healthcare professional, and patients seeking adjunctive cancer support are under the care of an oncologist. I understand that there are treatment options available for my condition other than acupuncture procedures. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. I understand the clinical and administrative staff may review my records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By signing below, I confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I agree with the current or future recommendations for care. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. YOUR SIGNATURE:
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This form was created inside of Academy for Five Element Acupuncture.